Alzheimer’s Delirium and Dementia Q 64
Which goal is a priority for a client with a DSM-IV-TR diagnosis of delirium and the nursing diagnosis acute confusion related to recent surgery secondary to traumatic hip fracture?
A. The client will complete activities of daily living.
B. The client will maintain safety.
C. The client will remain oriented.
D. The client will understand communication.
Correct Answer: B. The client will maintain safety.
Maintaining safety is the priority goal for an acutely confused client who recently had surgery. All measures to promote physiologic safety and psychosocial wellbeing would be implemented. Remove all potentially dangerous objects from the client’s environment; in a disoriented, confused state, clients may use objects to harm self or others. Have sufficient staff available to execute a physical confrontation, if necessary; assistance may be required from others to provide for the physical safety of the client or primary nurse, or both.
Option A: This client would not be able to complete activities of daily living, and safety is a priority over these tasks. Assess the client’s level of anxiety and behaviors that indicate the anxiety is increasing; recognizing these behaviors, the nurse may be able to intervene before violence occurs. Maintain a low level of stimuli in the client’s environment (low lighting, few people, simple decor, low noise level) because anxiety increases in a highly stimulating environment.
Option C: Interrupt periods of unreality and reorient; client safety is jeopardized during periods of disorientation; correcting misinterpretations of reality enhances client’s feelings of self-worth and personal dignity. Orient the patient to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result. Increased orientation ensures greater degree of safety for the patient.
Option D: The goals of remaining oriented and understanding communication would be appropriate only after the client’s acute confusion has resolved. Give simple directions. Allow sufficient time for the patient to respond, communicate, to make decisions. This communication method can reduce anxiety experienced in a strange environment. Avoid challenging illogical thinking. Challenges to the patient’s thinking can be perceived as threatening and result in a defensive reaction.